Note: This information was developed to provide consumers with general information and guidance about insurance
coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy.
For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact
the Department.
For children diagnosed with autism, early intervention and continued treatment is critical.
Beginning December 12, 2008, all individual and group health insurance policies and HMO
contracts must abide by the provisions of Public Act 95-1005 (215 ILCS 356z.14). This new Illinois
law provides coverage for the diagnosis and treatment of autism spectrum disorders for children
under 21, establishing an annual benefit of $36,000 for services provided pursuant to this Act. Here
are the basic facts about the new law.
When Will Coverage Under the Law Take Effect?
The law became effective December 12, 2008. Any policy issued, delivered, amended or renewed
after this date must include autism coverage required by the law.
If you are covered by a group health insurance policy (i.e., through your employer) issued before
December 12, 2008, you may have to wait until the date that the policy is amended or renewed
before your child is eligible for autism coverage under this law. Check with your group or your
insurer to find your policy’s renewal date.
If you are covered by an individual health insurance policy issued before December 12, 2008, you
may have to wait until the policy’s renewal date before your child is eligible for autism coverage
under this law. Check with your insurer to find your policy’s renewal or anniversary date.
Who Must Offer Autism Coverage?
All individual and group health insurance policies and HMO contracts (and voluntary health service
organization contracts) must abide by the new law. Health coverage provided to state, county, and
municipal employees (and employees subject to the Schools Code (105 ILCS 5/1-1 et seq.)) must
also provide the autism benefits.
The Autism Law Does Not Apply to:
o Self-insured, non-public employers.
o Self-insured health and welfare plans, such as union plans.
o Insurance policies or trusts issued in other states.
NOTE: For HMOs, the law does apply to contracts written outside of Illinois if the HMO member is a
resident of Illinois and the HMO has established a provider network in Illinois. To determine if your
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HMO coverage is required to provide treatment for autism, contact the HMO or check your
certificate of coverage.
The law does not change the autism coverage provided by public health care programs such as
FamilyCare and All Kids. Contact the specific program for more information about its autism
coverage.
Who is Covered?
Children under the age of 21 who have health coverage through an individual or group policy, as
described above, will receive coverage for the diagnosis and treatment of autism spectrum
disorders.
What is Covered?
The new law requires coverage for the diagnosis of autism spectrum disorders. For individuals
diagnosed with an autism spectrum disorder, the new law also requires coverage for the following
treatment:
o Psychiatric care;
o Psychological care;
o Habilitative or rehabilitative care (counseling and treatment programs intended to develop,
maintain, and restore the functioning of an individual); and
o Therapeutic care, including behavioral, speech, occupational, and physical therapies
addressing the following areas:
o Self-care and feeding
o Pragmatic, receptive, and expressive language
o Cognitive functioning
o Applied behavioral analysis, intervention, and modification
o Motor planning
o Sensory processing
Insurance companies may not impose dollar limits, deductibles or copayments for the diagnosis or
treatment of autism which differ from the dollar limits, deductibles or copayments established for
physical illness.
All services covered by this new law must be prescribed by a physician. However, some of the
services may be delivered by certified or licensed professionals who are not physicians (e.g.,
speech therapists, physical therapists, and occupational therapists). Insurance companies are
required to cover medically necessary care provided by these professionals.
What are the Limits of Coverage Under the New Law?
This law requires insurance companies to provide coverage for the diagnosis and treatment of
autism up to an annual limit of $36,000. An insurance company may provide coverage beyond this
limit, but is not required to do so by this law.
• Insurance companies are prohibited from limiting the number of visits to a physician or other
service provider.
• Treatments for conditions not diagnosed as autism will not apply to the $36,000 annual limit.
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The Illinois Serious Mental Illness Mandate (215 ILCS 370c) requires group insurance policies
covering more than 50 employees and all group HMO contracts to cover certain autism treatments.
Benefits provided by this new autism law are in addition to benefits provided by the Serious Mental
Illness Mandate. The Serious Mental Illness Mandate benefit limits are not altered by Public Act 95-
1005. For more information about the Serious Mental Illness Mandate, please see the Department’s
fact sheet on Mental Health Coverage at http://www.idfpr.com/doi/HealthInsurance/mental_hlth.asp.
Insurance companies may not categorize benefits historically covered under the Serious Mental
Illness Mandate as benefits now covered under this new law.
Can Insurers Refuse to Cover Individuals with Autism?
Group health insurance policies are not allowed to refuse enrollment based on health status.
For individual policies, Illinois law currently allows insurance companies to reject an application for
health insurance based on health status. However, beginning June 1, 2009, a new Illinois law
(Public Act 95-0958) will allow individuals with health insurance policies that provide dependent
coverage to elect coverage for dependents up to age 26, regardless of a dependent’s health status.
For more information on this law, please see the Department’s fact sheet on Dependent Coverage
(http://www.idfpr.com/DOI/pressRelease/pr08/HB5285DependentCoverage.pdf).
Is Autism Subject To Pre-Existing Condition Limitations?
Yes. Illinois law allows insurance companies to exclude coverage for pre-existing conditions,
including autism, for up to 2 years. Specific exclusion periods vary based on individual
circumstances, including the type of policy and an individual’s history of health insurance coverage.
For more information, please see the Department’s fact sheet on HIPAA and pre-existing conditions
(http://www.idfpr.com/DOI/HealthInsurance/HIPAA_preexisting_cond.asp).
Illinois law governing pre-existing condition limitations for dependent children will change in
significant ways due to the new dependent coverage law (P.A. 95-0958). For more information on
these changes, please see the Department’s fact sheet on Dependent Coverage
(http://www.idfpr.com/DOI/pressRelease/pr08/HB5285DependentCoverage.pdf).
NOTE: Individual and group HMO plans may not impose pre-existing condition exclusions, but may
limit coverage of pre-existing conditions through the use of deductibles and co-payments, for a
period of up to 12 months.
Can Insurers Deny Claims Based on Medical Necessity?
Like coverage for other conditions, coverage for the treatment of autism is subject to insurance
company determinations of medical necessity. An insurance company may deny coverage for a
certain treatment if the treatment is not medically necessary or does not result in improved clinical
status.
A treatment must be considered medically necessary if it is reasonably expected to:
o Prevent the onset of an illness, condition, injury, disease or disability;
o Reduce or ameliorate the physical, mental or developmental effects of an illness, condition,
injury, disease or disability; or
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o Help an individual achieve or maintain maximum functional activity in performing daily
activities.
If an insurance company denies a claim based on an adverse determination of medical necessity,
you may appeal the company’s decision. The company’s decision must be based on a
determination made by a physician with expertise in the most current and effective treatments for
autism spectrum disorders.
Appeal procedures and applicable state laws differ for HMOs and insurance companies. For more
information, please see the Department’s fact sheet on Medical Necessity
(http://www.idfpr.com/DOI/HealthInsurance/Medical_Necessity.asp).
For More Information
Call the Department of Insurance Consumer Services Section at (312) 814-2427 or
our Office of Consumer Health Insurance toll free at (877) 527-9431
or visit us on our website at http://insurance.illinois.gov